Faceoff for Trauma
Andrea L. Williams, PhD, RN
Emergency Education & Trauma Program Specialist
Associate Clinical Professor
UWHC & UW-SON
Case Presentation-January

You respond to 911 call for a ATV vs. tree at the
end of Patterson St. and Lake Mendota. A 28
year old man has been ejected over the
handlebars of a four wheeler. He was not
helmeted.
 Upon arrival they find the man sitting up dazed
by the tree. He is conscious. He has facial
deformity with blood from his nose and in his
mouth. Respirations are slightly rapid.
 What do you do?
Patterns of Injuries
Causes of Facial Fractures
Blunt trauma to face most frequent cause
Air Bag Injuries

Facial burns & corneal
abrasions/burns
 Head, neck & chest injuries in
short adults & children
Sports Related Facial Injuries
 72 percent of sports-related eye
injury occur in people less
than 25 years of age. Ninety
percent of eye injuries are
avoidable.
 Moderate to high risk sports
include: hockey, lacrosse, soccer, football,
volleyball and racket sports.
Playground Facial & Neck
Trauma
Motor Vehicle, Motorcycle, &
Recreational Vehicle Crashes
Facial Trauma from Diving &
Falls
Facial Trauma from Assaults,
Guns, Knives & Animals
Facial Trauma
Airway – Obstruction
Breathing – Aspiration
Circulation – Hemorrhage, Ischemic Injuries
Vision – Eye, Orbit or Retinal Injuries
Malocclusion & Dental Injuries
Cosmetic Effects
Neck – ABC Issues
Airway Obstruction
– Edema or hematoma of the pharynx
– Blood, vomit, bone, or teeth in the
airway
– Unsupported soft tissue
– Hematoma, air or edema in neck
compressing trachea
Bleeding & Hematomas
• Bleeding from eyes,
ears, nose, mouth
• Hemorrhage to the
point of hypovolemic
shock
- Arterial bleeding
• Hematomas &
expanding hematomas
Soft Tissue Injuries of the Eye
Corneal Injuries

Abrasions, lacerations, foreign
bodies
– Signs & symptoms
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Pain
Foreign body sensation
Photophobia
Decreased visual acuity
Anterior Chamber
Eye Injuries
Hyphema – blood in the anterior eye chamber
Grade I (1/3 full), Grade II (1/3-½ full), Grade
III (½-near completely full- Looks like an eight ball)
– Stretching & indenting globe
– Tears the cilary body & iris
– Signs & symptoms

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Blood in anterior chamber -  intraocular pressure
Deep, aching pain
Changes in visual acuity
Globe Injuries

Ruptured globe
– Penetrating eye injuries – projectiles,
stab wounds, missiles, foreign bodies,
sudden acceleration or deceleration, fxs.
– Signs & symptoms
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Acute, unilateral ↓ in visual acuity
Extrusion of intraocular contents
Flattened anterior chamber
Subconjunctival hemorrhage or hyphema
Decreased intraocular pressure
Restrcted extraocular eye movements
Retinal Injuries
Retinal hemorrhage from blunt trauma
– Signs & symptoms
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May or may not have ↓ visual acuity
White, cloudy visual discoloration
Lace-like vision
Flashing lights/shooting stars
Orbit Fractures

Orbital Blowout Fractures
– Caused by blunt blow from a large object (fist,
bat, ball, elbow) – Orbital floor gives way
– Signs & symptoms
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Pain - cheek
Swelling
Ecchymosis of lids & area around the eye
Subconjunctival hemorrhage
Facial asymmetry
Enopthalamos
↓ Ocular motion
Double vision/diplopia
Step-off fracture - pain, subcutaneous air
Hypoesthesia
Chemical Eye Injuries
Acid, alkaline,
organic substance
(splash) into eye
– Signs & Symptoms

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Pain
Corneal opacity
Coexisting
burns of lids
Nasal Injuries
Signs & Symptoms
 Epistaxis - Blood coming from
the nose
 Bruising around the eyes
 Difficulty breathing through
the nose
 Misshapen appearance (may
not be obvious until swelling
goes down)
 Pain
 Swelling
Treatment of Nasal Trauma

Reassure the patient
 Have them sit
leaning forward with
mouth open to
breath
 Elevate backboard if
need to immobilize
 Cold compresses/ice
Tooth Loss or Fractures
Place in Milk or Saliva – Replace w/i 30 Minutes
Maxillary Injuries
LaFort I & II - Unstable Injuries
LaFort I – Separates hard palate, teeth from maxilla
– Swelling, lip laceration, malocclusion
– ? Independent movement of maxilla from rest of face
LaFort II – Pyramid fracture of midface separates nasal &
lower maxilla from facial skull & cranial bones
– Massive facial edema
– Nasal swelling
– Malocclusion
– CSF rhinorrhea
Unstable Injuries: LaFort III
***Separates the entire midface from the cranium
– Maxilla, zygoma, orbits, cranial base fractures
– Massive facial edema
– Mobility and depression of zygomatic bones
– Ecchymosis
– Anesthesia of cheek
– Diplopia-doulbe vision
– Open bite or malocclusion
– CSF rhinorrhea
Le Fort Fractures
Mandible Injuries

Fracture sites at Canine & 3rd molar tooth, angle
of the mandible, & condyles

Signs & Symptoms
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Malocclusion
Inability to open mouth
Inability to close mouth
Pain on movement
Facial asymmetry
Edema or hematoma at fracture site
Blood behind or ruptured ear drum
Anesthesia of lower lip
Facial Injuries - Assessment
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Maintain airway, O2, suction, oral airway, ETT, King or
Combitube
Control the bleeding
Irrigate chemical burns to eyes or face
Stabilize impaled objects
Assess for visual changes
Patch/shield affected eye per protocol or medical direction
except in globe rupture – shield the other eye
Elevate head of backboard
Oral gastric tube to control vomiting
Assess for boney abnormalities
Assess for cranial nerve damage
– Loss of eye movements
– Facial, lid, eyebrow droop/movement
– Loss of facial lines
Ear Trauma

Lacerations
 Contusions – Battle Sign
 Frostbite
 Thermal or chemical burns
Perforated Tympanic Membrane
Diving, waterskiing, “Blob”
injuries
 Direct blow to ear
 Explosions
 Foreign Objects

Ear Assessment
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Hemorrhage?
Deformity?
Burns?
Frostbite?
Hemorrhagic
otorrhea?
Hearing loss?
Penetrating object?
Ear Trauma Treatments

Direct pressure/pressure dressing to stop the
bleeding
 If ear part amputated-wrap in saline & place in
plastic bag “on, but not really on ice”
 Stop the burning process, plastic wrap for pain.
If chemical injury – irrigate, irrigate, irrigate!
 Stabilize penetrating object
Neck Injuries

Depends on structures
affected
 Potential for bleeding
 Potential for ischemia
 Potential for airway
disruption
Non-spinal Cord Neck Injuries

Injuries to airway – trachea or larynx, blood vessels,
esophagus, glands, thoracic duct or brachial plexus

Signs & Symptoms
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Dyspnea
Hemoptysis
Active bleeding
Subcutaneous emphysema in neck, face, chest
↓ Breath Sounds/Absent
Pulsatile mass or  hematoma
Loss of anatomic prominence
Bruits
Hoarseness
Difficulty swallowing
Nerve deficits
Non-spinal Cord Neck Injuries
Blunt or Penetrating Trauma
 Treat the problem!!!
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Airway
Breathing
Circulation
? Spinal cord injury
Injury Prevention
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No Q-tips in ears
Helmets & face masks
Mouth guards
Ear muffs
Seatbelts over clavicle not neck!
Detroit Red Wings’ Captain Steve Yzerman was hit in the face with a puck while playing against
Calgary in 2004. Yzerman did not wear a face shield.